Musculoskeletal Flashcards
What is the majority of disease risk determined by in Ankylosing spondylitis
90% have HLA-B27
Male predominated
Describe the typical disease course for Ankylosing spondylitis
Before 30 years old
Insidious onset of lower back pain with spinal morning stiffness relieved by exercise
What are the 3 articular features of Ankylosing spondylitis
Inflammatory back pain:
Patients usually have morning stiffness and pain that starts in the sacroiliac joints and radiates to the buttocks. There is often tenderness of the sacroiliac joints. Advanced diseases sees the loss of lumbar lordosis and exaggeration of thoracic kyphosis with the neck stooped forward (Question mark posture).
Peripheral enthesitis:
Achilles tendonitis, Plantar fasciitis and tibial tuberosity. Painful in the morning - potential swelling
Peripheral arthritis:
Asymmetric joint involvement including - Hips, Shoulder, Chest wall, Pubic symphysis
What are the extra-articular features of Ankylosing spondylitis
Eyes - Acute anterior uveitis
CV - Aortitis to AR, Fibrosis to AV Block
Resp - Limited chest expansion to Restrictive, Fibrosis of upper lobes
Renal - IgA nephropathy
Neuro - 2o to fractures of fused spine - Cauda equina
Met - Osteopenia/Osteoporosis
What are the investigative results in Ankylosing spondylitis
Potential normocytic anaemia - FBC
Inflammatory markers may be elevated - ESR, CRP
Sacroiliitis or enthesitis/Spinal Osteopenia - XR
MRI - More sensitive
DEXA - Osteoporosis
Seronegative - -ve Rheuamtoid factor and ANA
What is Gout
Gout is a crystal arthropathy.
This is arthritis due to monosodium urate (MSU) crystal deposition within joints causing acute inflammation and tissue damage. These deposits are called Tophi
What joints are usually affected in Gout
Most of the time it is the MTP joint of the big toe (podagra)
Other joints: Ankle, Foot, Small joints in hands, Wrist, Elbow, Knee
Potential to be polyarticular but is usually mono
What is the primary cause of Gout and what are the precipitating factors to this
The primary cause if hyperuricaemia usually due to inadequate excretion of uric acid from purine nucleotides
RFs: MALE
Dietary: Meat, Seafood, Alcohol, High triglycerides
Drug: Diuretics, Chemotherapy
Medical: Obesity, CHD, CKD, DM, HF, HTNm Psoriasis
What are long term complications of Gout
Urate deposits - Tophi
Renal disease - Stones, interstitial nephritis
What are the signs and symptoms of Gout
Swollen, tender, red joints - Peaks within 24hrs. Attack resolves in 5-15 days untreated.
Potential - Tenosynovitis, bursitis and cellulitis
Chronic tophaceous gout - Large deposits around extensors and ears
Crepitus and deformity
What are the investigative findings in gout
Negatively birefringent urate needle-shaped crystals and increased WCC - Polarised light microscopy of synovial fluid
High serum urate
Junta-Articular erosions - XR
What is Pseudo-gout
This calcium pyrophosphate deposition rather than monosodium urate and usually affecting larger joints
What is the presentation of Pseudo-gout
Acute monoarticular or oligoarticular arthritis.
Usually affects the knees
Often also wrists, shoulders, ankles, hands and feet. Almost any joint may be affected.
Presentation is similar (but usually milder) to acute gout, with acute joint pain and swelling.
Affected joints are acutely inflamed with swelling, effusion, warmth, tenderness and pain on movement.
Attacks may be associated with fever and raised white cell count.
What are the investigative findings in Pseudo-gout
Positive intracellular or extracellular birefringent rhomboid-shaped crystals - Polarised light microscopy of synovial fluid
Soft tissue calcium deposition - XR
What are the risk factors and associations of Fibromyalgia
RFs Female Middle age Low household income Divorced Low educational status
Chronic fatigue syndrome
IBS
Chronic headache syndrome
What are the main signs and symptoms of Fibromyalgia
Pain - Chronic (>3months) and widespread (Left and right, above and below diaphragm)
Fatigue - Profound with unrefreshing sleep and significant fatigue and pain with small increases in exertion.
Widespread and severe tender points
Other features: Morning stiffness Paraesthesiae Headaches Low mood
What are investigations in Fibromyalgia geared towards
Exclusion of Rheumatoid arthritis Polymyalgia rheumatica Vasculitis Hyothyroidism Myeloma
Who usually gets Giant cell arteritis
Temporal arteritis:
Woman older than 50
If they are younger then consider Takayasu’s.
It is associated with Polymyalgia rheumatica
What are the signs and symptoms of Giant cell arteritis
Headache
Temporal artery and scalp tenderness
Loss of vision
Malaise
Dyspnoea
Weight loss
Morning stiffness
Risk of irreversible bilateral vision loss
What are the normal investigative results in Giant cell arteritis
Increased ESR and CRP Thrombophilia Increased ALP Anaemia Biopsy within 14 days of starting steroids - Beware of skip lesions
How is Giant cell arteritis treated
No visual symptoms - Oral Prednisolone
Visual symptoms - IV MethylPrednisolone
What are the symptoms of localised and generalised Osteoarthritis
Localised disease:
Hx Physically active
Pain and crepitus on movement
Pain is worse with prolonged activity.
Morning stiffness lasting under 30 minutes. (Longer than this may be suggestive of RA)
Joint instability can lead to perceived lack of power
Generalised disease:
Joint tenderness
Derangement and bony swelling (Heberden’s at DIP, Bouchard’s at PIP)
Reduced range of movement
Which joints are usually affected in localised and generalised Osteoarthritis
Localised:
Knee or Hip
Generalised:
DIP, PIP, CMC joints
What are the investigative findings in Osteoarthritis
Plain XR Loss of joint space Osteophytes Subarticular sclerosis Subchondral cysts
Potentially elevated CRP
What are the risk factors for Carpal tunnel syndrome
Women
Genetic:
Short stature
Fix
Hereditary neuropathy
2o: Obesity Colles fracture Trauma to wrist SOL in wrist DM Hyperthyroidism Menopause Inflammatory arthritides Acromegaly Renal dialysis Amyloidosis
Pregnancy
What are the characteristic features of Carpal tunnel syndrome
Aching pain in the hand and arms (especially at night), and paraesthesiae in thumb, index, and middle fingers: relieved by dangling the hand over
the edge of the bed and shaking it (remember ‘wake and shake’).
There may be sensory loss and weakness of abductor pollicis brevis ± wasting of the thenar eminence. Light touch, 2-point discrimination, and sweating may be impaired.
What are the investigative findings in Carpal tunnel syndrome
Tinnel’s - Tapping lightly over the median nerve at the wrist causes a distal paraesthesia in the median nerve distribution.
Phalens - Flexing the wrist for 60 seconds causes pain or paraesthesia in the median nerve distribution.
ENG - The median nerve is stimulated proximal to the carpal ligament and compound muscle action potential is picked up over the thenar eminence.
EMG - Useful but ENG better
US - Confirming
What is Systemic sclerosis
A multisystem autoimmune disease characterised by functional and structural abnormalities of small blood vessel, fibrosis of skin and internal organs, and production of auto-antibodies
What are the antibodies involved in Systemic sclerosis
90% of cases are ANA positive
30-40% have anticentromere antibodies
Limited: 70-80% Anticentromere antibodies
Diffuse: 40% Antitopoisomerase-1
20% anti-RNA polymerase
What are the 2 main types of Systemic sclerosis and the main features of both
Diffuse Cutaneous Systemic Sclerosis (40%) Raynaud's phenomenon Followed by skin changes with truncal involvement Tendon friction Joint contracture Early lung disease Heart, GI and renal disease Nail-‐fold capillary dilatation
Limited Cutaneous Systemic Sclerosis (60%) CREST Syndrome Calcinosis Raynaud's phenomenon (O)esophageal dysmotility Sclerodactyly Telangiectasia
What are the signs and symptoms of Systemic sclerosis separated by system
Skin - Raynaud’s disease
Hands - Initially swollen and painful then later they thicken and tighten and become shiny. Changes in pigmentation and Finger ulcers
Face - Microstomia - Puckering of skin around mouth. Telangiectasia
Lungs - Fibrosis to hypertension
Heart - Pericarditis or effusion, fibrosis, HF
GI - Dry mouth, oesophageal dysmotility, GORD, Gastric paresis
Kidneys - Hypertensive renal crisis, Chronic renal failure
Neuromuscular - Trigeminal neuralgia, wasting and weakness
Others - Hypothyroidism, impotence
